Provider Demographics
NPI:1235456955
Name:LAVENDER, REBECCA TYSON (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:TYSON
Last Name:LAVENDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:TYSON
Other - Last Name:CORNELISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 278980
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-276-7640
Mailing Address - Fax:585-325-4255
Practice Address - Street 1:454 E BROAD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1724
Practice Address - Country:US
Practice Address - Phone:585-276-7640
Practice Address - Fax:585-325-4255
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY266403207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program